NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 2 of 5
A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:
Correct Answer: C
Rationale: Using Nägele's rule, subtract 3 months and add 7 days from January 15, resulting in October 22.
Question 3 of 5
A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:
Correct Answer: C
Rationale: Smoking on a full stomach minimizes nicotine's effect on gastric acid, reducing ulcer irritation. Other options still stimulate gastric acid secretion.
Question 4 of 5
The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:
Correct Answer: D
Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
Question 5 of 5
The nurse is caring for a client post-appendectomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: A temperature of 101.5°F post-appendectomy suggests infection (e.g., abscess), requiring immediate intervention. Pain (
A), serous drainage (
C), and absent bowel sounds (
D) are expected initially.